The objective of this study is to reflect
on the knowledge, competencies and skill that must be promoted during the
academic education of nurses for an effective professional practice in view of
a multiple-victim incident (MVI). This is an integrative literature review
regarding academic nursing education. The literature survey was performed on
the BDENF, LILACS, SciELO, MEDLINE, Web of Knowledge and HighWire Press
databases, using the following descriptors: higher education; nursing
education; emergency nursing; and mass casualty incidents. The publications
permitted considerations regarding the following themes: particularities;
competencies and skills essential in nursing practice in view of
multiple-victim incidents; and the professors' strategies to promote those
competencies and skills. The literature analysis demonstrated that nursing
education should be configured as a space to develop critical thinking skills,
which requires professors to have an eclectic educational background.

In the
Brazilian context, violence and traffic accidents have represented one of the
main public health problems in the country since the end of the 1970's(1).
As a part of this problem, Multiple Casualty Incidents (MCI), which produce
more than five victims, reveal a disequilibrium between available resources and
demands, but whose needs can be attended to when protocols are put in practice(2-3).
These complex events demand combined efforts with a view to effective health
care.

In
this study, the terminology of the American College of Surgeons' Committee on
Trauma is used, with a view to universally standardizing the terms used in care
delivery to trauma victims, i.e.: Multiple Casualty Incidents (MCI) for events
that result in more than five victims, and Mass Casualty Events (MCE), in case
of natural or man-produced disasters, involving 20 or more victims(4).

These
events are included in the International Classification of Diseases (ICD) under
the title external causes, which cover accidental events and environmental
circumstances as causes of injuries, poisonings and other adverse effects(5).
According to data from the Informatics Department of the Brazilian Unified
Health System (DATASUS) for 2006, external causes were responsible for about
14% of deaths in the country, totaling 128,388 fatal victims(6).
Concerning the Years of Potential Life Lost (YPLL), an important health
indicator, it is noteworthy that, in the particular case of accidents and
violence, the indicator increased by about 30% in recent years(7).

With
regard to natural disasters, a unanimous consensus exists in literature that
these are a global reality. In that context, between 1993 and 2002, the
American continent was the second most affected by natural disasters. In this
respect, the Brazilian reality can be characterized by the frequency of
cyclical natural disasters, especially floods all over the country, and the
relevance of draughts in the Northeast(5).

A
Californian study estimates that disasters affect more than 255 million people
each year(8). Estimates from a Canadian study appoint that, in 2003,
a natural disaster affected one in every 25 people around the world. Besides,
the exponential transportation and industrial growth in that period entailed
greater technological risks. In combination with population growth, this
enhances the risk of mass-casualty catastrophes(9).

In
view of these data, although there are no statistics for the actual proportion
of Multiple Casualty Incidents in the Brazilian health context, these are
frequent problems nowadays, in which traffic accidents, besides natural
disasters, represent important etiologies of these events and entail
significant consequences for the Brazilian Unified Health System, from the
viewpoint of human and material as well as financial resources. Therefore, this
reality demands more in-depth studies, which can clarify the actual proportions
of Multiple Casualty Incidents in the Brazilian health panorama.

In view of this
epidemiologically relevant picture of Multiple Casualty Incidents (MCI), it is
clear that the care delivered to the victims of these events is a decisive
factor to minimize their catastrophic consequences, entailing an increase in
the victims' survival rates. It is in this sense that education for nurses, as
well as for the entire multiprofessional health team, represents an essential
factor, as the educative process constitutes a tool for training and to
encourage protocols, in the scope of health professionals' continuous
improvement. It is in this interim that the framework of this process is
highlighted: the academic education process of nursing professionals.

It should be highlighted that
we consider the essential nature of generalist education for nursing
professionals. Consequently, we understand the impossibility (i.e. inadequacy)
of preparing professionals with comprehensive and specific training for urgency
and/or emergency care, and specifically for care delivery to Multiple Casualty
Incidents. Nevertheless, we are convicted that comprehensive nursing education
should cover the encouragement of knowledge, skills and competences required
for nursing professionals' effective and problem-solving actions in view of Multiple
Casualty Incidents (MCI).

In that context, the research
question that is raised is: what knowledge, competences and skills should be
encouraged during academic nursing education for effective professional actions
in response to Multiple Casualty Incidents? And, therefore, what teaching
strategies are put in practice in the academy to consolidate these skills?

In
summary, our study aims to reflect on the knowledge, competences and skills
that should be encouraged during academic nursing education for effective
professional actions in response to Multiple Casualty Incidents (MCI).

METHOD

This is
an integrative literature review about nursing students' education to act on
Multiple Casualty Incidents (MCI). Bibliographic research is developed based on
previously elaborated material, mainly comprising books and scientific papers,
with a view to reviewing existing literature, identifying state-of-the-art
knowledge on the theme under analysis, and therefore represents the framework
for any scientific study(10).

To
consolidate our work, we developed the bibliographic survey on the Internet, in
the databases BDENF (Banco de Dados em Enfermagem), LILACS
(Latin-American and Caribbean Health Science Literature), SciELO (Scientific
Electronic Library Online), MEDLINE (Medical Literature Analysis and Retrieval
System Online), Web of Knowledge and HighWire Press. The following descriptors
were used to locate the studies: higher education, nursing education, emergency
nursing, and mass casualty incidents. We developed the research in February and
March 2011.

The
literature review was structured in three phases, which were: first, we
identified the controlled descriptors in BIREME (Virtual Health Library),
through the DeCS (Descriptors in Health Sciences), selecting those descriptors
that are considered pertinent to develop the research - Educação
Superior/Education, Higher/Educación Superior, Educação em
Enfermagem/Education, Nursing/Educación en Enfermería, Enfermagem em
Emergência/Emergency Nursing/Enfermería de Urgencia and Incidentes com Feridos
em Massa/Mass Casualty Incidents/Accidentales Casuales Masivas. The combination
of these terms was used as a search strategy in the databases; in the second
phase, the research was accomplished in the abovementioned databases, using
these descriptors; and, finally, the studies were subject to critical analysis,
excluding those studies that were not in line with the research scope or were
repeated in different databases.

We attempted to select papers that addressed the
following thematic pillars, which constituted the structural axis of our study:
1) the peculiarities of Multiple Casualty Incidents, including the
characteristics that should guide care for these catastrophic events; 2) the
competences and skills that should be developed through academic training and
which are essential for nurses to act in cases of Multiple Casualty Incidents;
and 3) teaching strategies to encourage these competences and skills that are
put in practice and aimed for nowadays. In this interval, we selected Brazilian
scientific production, available in full text, which addressed these pillars as
a whole or independently. These productions furthered considerations about the
abovementioned thematic pillars, which will be addressed in this study.

As inclusion/exclusion
criteria, we selected those studies in line with the theme, available in full
text and published between 2000 and 2011.

RESULTS AND DISCUSSION

Based on
the literature studied, we could make considerations and present results, which
were grouped in the following thematic pillars, discussed next: the
peculiarities, competences and skills essential for nurses' actions in cases of
Multiple Casualty Incidents (MCI) and which should be developed in academic
education; and teaching strategies to encourage these competences and skills.
Before discussing these pillars, however, we present a categorical analysis of
the studies included in this integrative literature review.

Aspects of
literature on higher nursing education and MCI

To consolidate the results,
analytical activities were developed, considering 60 scientific studies, which
are systematically presented in Chart 1.

The
scientific studies analyzed compose the following categories: 41 original
research papers (68%); six reviews; five supplements; four studies resulting
from course conclusion papers and dissertations; two reflections; one update;
and one debate. The time dimension of the publications ranged between 2000 and
2011, with the highest publication incidence level in 2008 (17 papers = 28%).

As
for journals, 36 were published in international (60%) and 24 in Brazilian
journals (40%). In this context, the Revista da Escola de Enfermagem da USP
(REEUSP) and the Revista Brasileira de Enfermagem (REBEN) stood out in
Brazil, and Chest and AMIA Annual Symposium Proceedings internationally, all of
which published five of the papers analyzed (8%).

MCI: complex and peculiar events

Multiple Casualty Incidents
produce more than five severe victims, showing a disequilibrium between
available resources and demands, but whose needs can be attended to by putting
in practice protocols(2-3).

Care
in cases of Multiple Casualty Incidents should center on a principle that is
different from that characteristic of daily practice: the fundamental rule is to
enhance the maximum level of wellbeing for as many people as possible(3).
In other words, the premise that the best medical resources should be offered
to the most severe victims should be replaced by the concept of the best
medical care for as many victims as possible, which involves the right moment,
the adequate time and the minimal use of resources, i.e. efficient and precise
professional action(2).

In
this perspective, it is fundamental to prepare health professionals to work in
a problem-solving way. That is the case because Multiple Casualty Incidents
involve peculiarities the actors who will work in these situations should be
very familiar with to solidify existing care, avoiding the production of
further victims and the aggravation of existing patients.

An
English study establishes that it should be highlighted that Multiple Casualty
Incidents (IMV) represent a reality in the global health panorama, with
distinguished etiologies according to each territory. Denying this fact can
imply mistakes that can easily lead to three forms of denial: this is not going
to happen here, this is not going to happen to me or someone will take care of
the problem(11). Such mistakes can entail irreparable damage for the
subjects involved in this process.

In
this sense, in didactical terms, it is evidenced that care delivery to Multiple
Casualty Incidents should be based on three fundamental pillars: 1) command,
which should be properly identified to guarantee the management of care
delivery, adding up the stakeholders' efforts; 2) communication, which involves
contact between commands and the fundamental figure of the regulation central,
which should vouch for attendance to all needs in the context; and 3) control,
which results from the effective consolidation of the previous pillars, ranging
from safety on the scene to the management of facts (integrated team care,
guaranteed information to family members and the media, etc.)(2).

Therefore, pre-hospital care
should be systemized in three phases, whose success is an interdependent
factor, i.e.: screening, treatment and transportation. Screening is the
verification of cases to determine priority health care needs and the adequate
place for treatment, marking compliance with the fundamental principle of care
delivery to Multiple Casualty Incidents (MCI): treating as many victims as
possible, as fast as possible and in the best possible way(3). This
is achieved through the rapid assessment of the victims' clinical conditions,
which should take no more than 60 seconds per victim(2).

An Australian study that
highlights the evolution of screening systems over the years highlights that,
since World War II, the patient screening procedure is considered the main sole
factor that contributes to the survival of Multiple Casualty Incident victims(12).

Therefore,
screening methods should be simple, standardized and fast. Among currently
existing screening protocols, the START (Simple Triage And Rapid Treatment)
stands out, which identifies victims with the help of colored labels, using
physiological respiration, perfusion and mental status parameters(2).
Through this protocol, victims are classified in four priority categories, with
their respective colors: dead or expecting (black); immediate (red); late or
delayed (yellow); and minor or minimal (green)(2-3,13).

International studies underline
the relevance of electronic screening methods. A study at the Stanford
University, California, demonstrated improved care delivery to Multiple
Casualty Incidents (MCI) when electronic instead of paper-based screening
systems are used, highlighting: the safety and efficacy of these methods and
the improved identification of victims and, consequently, family members'
anticipated comfort. During a deployment of the paper and electronic triage
tags, 19% to 25% fewer radio calls were made during the event in the electronic
triage team(14).

In addition, a Finish study
emphasizes that screening has been considered the cornerstone of mass casualty
disaster situation management and showed to be the most important determinant
of care delivery to victims, with clear advantages when using a screening
system based on the commercial mobile telephony network and Radiofrequency
Identification (RFID) pattern, permitting: patient labeling; screening information
communication and medical exams to receive medical installations; and
communication of screening information to the incident / medical command
central(15).

Based
on this classification, treatment should be provided, established in priority
areas according to the victims' severity, as determined in the screening phase.
These areas are identified using colored canvas or flags. Thus, the medical
priority areas are: priority 1 (red), involving victims with injuries that
represent risk of death, but which are compatible with survival through minimal
intervention; priority 2 (yellow), in which injuries are significant and
require medical care, but can wait without being life-threatening; priority 3
(green), grouping victims with minor injuries, for whom treatment can be
postponed for hours or days; and priority 4 (black), with deceased victims or
people with improbable chances of survival, who should not be abandoned, but
provided with comfort measures as possible(2-3).

Finally,
the victims' transportation should be accomplished according to the established
needs. This should take place in an organized way, through a traffic flow that
avoids congestions and accidents.

In
view of the above, the complexity of care delivery in case of Multiple Casualty
Incidents (MCI) is clear. This should be based on care systemization, adding up
the efforts of all professionals trained to act in these events, with a view to
avoiding victims' worsening or the appearance of new victims. Besides, it is
fundamental for all sectors to be involved in this process. An Australian study
revealed the concerning facts that, in case of a catastrophe of great
proportions on Australian territory, between 61% and 82% of severely injured
patients could not have immediate access to surgery rooms, and that between 34%
and 70% could not have immediate access to ICU beds, statistics that
demonstrate the lack of preparation for effective care delivery in case of
Multiple Casualty Incidents. Based on these data, the authors recommend working
towards a national agreement on disaster preparation referral standards and the
periodical publication of hospital performance indicators to improve
catastrophe prevention(16).

In this context of unparalleled
need for incessant preparation to act in case of Multiple Casualty Incidents,
nursing represents a fundamental piece in joint care activities. These
professionals' education represents an unquestionably important factor in this
process. An Israeli experience report clarified the importance of the educative
training factor to reduce mortality and morbidity in case of mass disasters,
which can only be achieved through organized and concise planning(17),
factors that will be further discussed next.

Essential competences and skills for nurses
working in cases of MCI

Nursing professionals'
activities in Multiple Casualty Incidents is supported by the Law that
Regulates Professional Nursing Practice No. 7498/86, which established direct
care delivery to critical patients and activities of greater technical
complexity that require scientific knowledge and immediate decision-making
skills as nurses' exclusive activity(18).

Literature presents emergency
work as a peculiar area, paradoxically characterizes as a field that produces
suffering but is a source of accomplishment. Thus, emergency professionals
clarify (...) vanity and professional pride to practice problem-solving
medicine, capable of saving lives in view of imminent death(19).

A study among nurses from the
Massachusetts General Hospital in Boston highlighted that care delivery in
disasters represents unique challenges and, in view of the global
epidemiological relevance of Multiple Casualty Incidents, it should clearly be
understood that the role of nursing in disaster medicine will continue growing,
demanding adaptations from all stakeholders with a view to care improvements in
these catastrophic events(20).

In
this context, the analysis of literature indicated the need for a specific
profile to work in the emergency sector, appointing, among other factors:
clinical competency, performance, holistic care and leadership(21);
education and professional experience, skill, physical, stress-coping, rapid
decision-making, priority-setting and teamwork abilities(22);
aptitude to obtain the patient's history, physical examination, immediate
treatment, concerned with life maintenance and patients' orientation to
continue treatment(23).

In other words, these
professionals' academic preparation (...) demands the need for conceptual
and methodological theoretical education that enhances competences for
comprehensive care (...)(24). Thus, among essential competences
for emergency nursing practice, clinical reasoning for decision making and
skills to readily perform interventions stand out(25).

Another
essential factor for nursing professionals working in emergency situations is
theoretical knowledge, knowledge articulation as a way to conduct solid health
practices. From the comprehensive perspective of their academic education, it
is mandatory for nursing professionals to be prepared to act in health
accumulation practices in cases of Multiple Casualty Incidents, events of
unarguable epidemiological importance in the current health context, which
demand permanent education.

A
study at the University of Toronto, Canada, investigated professionals'
educative preparation to act in cases of Multiple Casualty Incidents. The
interviewed medical directors revealed that only one-third (39%) of institutions
required disaster training programs for physicians, nurses and other health
professionals. Besides, only 9% of the centers had taken measures for military
agencies to participate in workers' training(26).

It is
in this context that nursing stands out as an unmatched member in care delivery
to these catastrophic events, and should work together and fine-tuned with
other professionals, joining care actions and moments of dialogue with the
victims and relatives, offering fundamental psychological support for
comprehensive care delivery to these subjects' health(27).

Finally,
we underline a relevant aspect of professional practice in emergency care:

at the same time as
they are circumscribed (...) to a specific organizational culture, whose motto
is expressed as acting fast to save lives, (...) they are not immune to the
reproduction of socially solidified prejudices and grudges(19).

How
can this problem be minimized then, guaranteeing qualified, equanimous and
problem-solving care, based on ethics, the true sign of health services? This
question is particularly importance when considering care delivery to Multiple
Casualty Incidents, whose fundamental pillar is the screening principle as a
way to guarantee significant care delivery to victims. We defend that permanent
education for health professionals is the guideline of this process, permitting
the establishment of protocols, care standards and spaces for professional
reflection, as means to enhance systemized and therefore effective health
actions.

In this context, a Norwegian
study underlines that screening precision significantly improves when
well-trained and experienced professionals working in their habitual
environment apply screening criteria(28).

In this perspective, nursing
professionals' academic education represents the framework of this process,
which is permeated by some fundamental subjective aspects that need to be
addressed, which are: at this moment, students go through the inexperience and
immaturity characterize of their phase of life at the time; they mostly
experience the traditional pedagogical model, which hampers the understanding
about the transformative function of the knowledge addressed; they express
communication difficulties during their first practical contact with users,
when they have to deal not only with their emotions, but also with those of
other people; and, as a complex result of these elements, they report signs of
anxiety, fear and anguish(29).

What strategies, then, should
permeate these subjectively peculiar subjects' education, with a view to
consolidating critical and reflexive nursing professionals who are capable of
efficient actions when confronted with Multiple Casualty Incidents? This aspect
will be discussed next.

Academic education: the fundamental
framework

Across history, Nursing
professionals' education has been subject to great changes, which received
influence from this profession's representation over time. In 2001, however, a
great advancement was consolidated, when the National Curricular Guidelines for
Undergraduate Nursing Programs are established through CNE/CES Resolution No.
3, issued on November 7th 2001.

In summary, the pedagogical
principles the Curricular Guidelines for Undergraduate Nursing Programs
clarified are: the competence-based pedagogy; the principle of learning to
learn; generalist, humanistic, critical and reflexive education; and
student-centered education, with teachers acting as facilitators(30).

Thus, the goal is to prepare
health professionals within a perspective of complexity and holism, with
multiprofessional actions in response to the needs of our Unified Health
System. Thus,

(...) today,
education plays a role that goes beyond that teaching that aims for mere
pedagogical and didactical scientific updates, that is, it turns into the
possibility of creating spaces for participation, reflection and formation
(...)(31).

Therefore, the academic
restructuring of health/nursing professionals' education process should involve
the following principles: acknowledgement of the multidisciplinary nature of
professional practice; encouragement of clinical reasoning; valuation of the
articulation between theory and practice; use of active teaching/learning
methods; and curricular flexibility(24).

Thus, when we attempt to
understand the competences and skills needed for nurses to act effectively in
cases of Multiple Casualty Incidents (MCI), we are placing them in this generalist
context, which aims to establish comprehensive education, based on critical
thinking, autonomy, scientific knowledge, without neglecting ethics and
humanescence. The use of active methods presupposes students who are at the
center of the process, teachers who act as learning facilitators, in which
problemization is the fundamental method, as knowledge, which is volatile,
should not be transmitted, as what is imposed/desirable is to learn how to
learn(32).

One essential aspect is related
to the fact that nurses' care practice reflects their education process:

Although many studies call attention to care
humanization (...), we believe this proposal will be more significant if we
consider the humanization of teaching(33).

In this perspective, the
framework for the promotion of humanescent health practices is the formation of
humanescent health professional, a role the academy needs to play and which
mainly involves teachers' preparation to put in practice the curriculum ideals
of this process. In other words, care humanescence reflects the subjects who
are part of it and who, in a continuous and incessant cycle, are improved
through humanescent teaching.

A study revealed that student
aim for a teaching form in which teachers stimulate the students through the
use of practical classes that involve students' participation in their
planning, taking into account their experiences; which privilege students'
learning instead of teachers' teaching; which enhance students' reflection on
what they learn and the establishment of relations with their life; in sum,
students aim for teaching through discovery, which represents meaning for them(34).

Thus, the ideal teacher
is defined as a person who thoroughly knows the subject (s)he is teaching, with
clarity, showing different ways of teaching, without discriminating among
students, knowing how to organize teaching and preserving good relations with
the students(35).

A
German study presents the experience of building an academic curriculum for
medical care in disaster cases, showing that knowledge and skills development
in practical exercises can serve as basic training for medical practice in all
types of emergency situations, a factor that can directly influence
improvements in care delivery to victims(36).

Similarly,
an Indian study emphasizes that the preparation process for a disaster is
precisely dynamic. Professional training should include: ethical base for the
allocation of scarce resources in a Multiple Casualty Incident; orientation on
how an incident command system will work in a mass casualty disaster event; how
to recognize the signs and symptoms of specific risks and treatment of specific
conditions; basic and advanced life support; and isolation, decontamination and
screening protocols(37).

Putting in practice this
idealized education requires a learning environment that facilitates this
process, because it is through the experience process that man gives meaning
to something, through the apprehension and interpretation of this something for
his life(38).

Thus, experience activities
further students' competence and skill development, working with the real as a
way to consolidate critical health professionals, as

bringing corporeity into the heart of
education as an irradiating focus means bringing life and experiences into the
education process and calling upon Pedagogy to pedagogize life(39).

What
should not diverge in this process is the establishment of comprehensive
education for nursing professionals. Therefore,

(...) aiming for
the excellence of undergraduate Nursing education, as the fruit of educative
practice based on the integrated curriculum, means that one cannot lose out of
sight the triad: challenging, daring and innovating(40).

Through this triad, we believe
that one can seek teaching strategies that further students' consolidation of comprehensive
skills and competences, so that they can act in an effective and
problem-solving way, always aiming for care quality.

CONCLUSION

This
reflexive study allowed us to envisage different aspects of the thematic
pillars peculiarities of Multiple Casualty Incidents (MCI), essential
competences and skills for nursing activities and teaching strategies to
encourage these competences and skills.

In
this perspective, we could notice the epidemiological importance of Multiple
Casualty Incidents in the contemporary context, events that are part of the
International Classification of Diseases (ICD) under the title of external
causes. This is the case despite the non-existence of statistics that show the
actual proportions of these events in the Brazilian health scenario. Thus, it
was explained that these currently represent frequent problems, in which
traffic accidents, in addition to natural disasters, constitute important
etiologies of these events, with significant consequences for the Brazilian
Unified Health System, considering human and material as well as financial
resources. This reality underlines the need for further research to reveal the
actual proportions of Multiple Casualty Incidents (MCI) in the Brazilian health
context.

In this perspective, we assert
that academic education constitutes the framework of this process. This
assertion is based on the premise that knowledge, core competences and skills
exist for nurses to act in cases of Multiple Casualty Incidents which should
initially be taught in the academic environment. In other words, we do not
intend to defend specific education for nurses in any way, but to envisage
comprehensive education that permits refining health professionals with a view
to the consolidation of care excellence.

Thus, we
hope to contribute to the development of further research to unveil the
incipient nature of Multiple Casualty Incidents today and, above all, to
cooperate with the affirmation of the education process as the guiding wire for
professional qualification and, consequently, for the improvement of the health
work process. In addition, we attempt to apprehend the aspects that should
permeate nurses' academic education and, thus, contribute to clarify teaching
strategies that facilitate students' learning process so that, through
generalist education, they can be prepared through problematizing educative
tasks that enhance the knowledge, core competences and skills that are
essential for effective actions in cases of Multiple Casualty Incidents (MCI).

Hence,
the intention nowadays is the understanding of the fundamental health/education
dyad, in a process that starts in the academy, when values should be
constructed within the framework of complexity, holism, problematization,
experiences, in short, through educative tasks in which there are no
protagonists, but co-participants in a refinement process of competent
professionals who are committed to care quality.

In
sum, we defend that one cannot ignore the essential importance of the
perspective of the unfinished in the Nursing profession. In other words, we
consider that complete professional education will never be achieved, as
permanent education is a factor sine qua non of nurses' professional
practice.